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doi:10.1111/jpc.12751
Letters to the Editor Dear Editor, THE IMPORTANCE OF PHYSICAL EXAMINATION IN PATIENTS WITH MENTAL HEALTH PRESENTATIONS An 8-year-old girl was referred by her GP to the out-patient department for assessment of learning difficulties. She was triaged to the Behaviour Clinic. At the appointment, her mother expressed concern about the limited support her daughter was receiving at school and also requested a brain scan to investigate her poor memory. It was immediately apparent that the mother had poor cognitive function, with limited understanding about her daughter’s symptoms, capacities and needs. On physical examination the girl appeared generally healthy and non-dysmorphic. A large (approximately 8 × 10 cm), firm, non-tender mass was palpated in the lower central abdomen. On further questioning, neither the mother nor the girl were able to provide much information regarding the mass or how long it had been there. The mother thought it was due to constipation. An urgent ultrasound was arranged. The appearance was consistent with a complex ovarian teratoma. She was referred to the paediatric gynaecologists and underwent laparoscopic resection without complication. She recovered well from the operation and returned to the Behaviour Clinic for on-going care. Over recent decades, an increasing proportion of the casemix of paediatricians in Australia involves developmental, behavioural and mental health problems.1,2 Doctors provide skilled assessment and management of developmental and mental health problems in children, including referrals to other health, education and social service care providers. However, it is also incumbent upon doctors to take a full history and perform a physical examination to exclude any causative or unrelated medical condition. Many children have limited contact with medical professionals, and so it is important to perform a thorough medical evaluation when they are seen. In addition, preventive health care issues such as nutrition, exercise, minimising ‘screen time’ and immunisation should be discussed. This case illustrates the importance of taking the opportunity to ‘do the doctor thing’. This is particularly important when seeing families with low cognitive function or psychosocial disadvantage. Dr Doris Tham1 Dr Daryl Efron2,3,4 1 Paediatric Registrar, Centre for Community Child Health, 2 Paediatrician, The Royal Children’s Hospital, 3Senior Research Fellow, Murdoch Childrens Research Institute, and 4 Senior Lecturer, Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
References 1 Hewson PH, Anderson PK, Dinning AH et al. A 12 month profile of community paediatric consultations in Barwon region. J. Paediatr. Child Health 1999; 35: 16–23.
Conflict of interest: There is no conflict of interest connected to this paper.
932
2 Hiscock H, Roberts G, Efron D et al. Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network. Med. J. Aust. 2011; 194: 392–7.
Dear Editor, ANTIBIOTIC PRESCRIBING IN THE PAEDIATRIC EMERGENCY DEPARTMENT AND THE IMPACT OF EDUCATION Increasing numbers of children in the UK are attending the emergency department (ED).1 Data on antibiotic prescribing in this setting are limited. We aim to describe antibiotic prescription in a busy UK paediatric ED and to assess the impact of a targeted educational programme on optimal antibiotic prescribing. We conducted a retrospective study of all children attending the ED for 2 weeks in November 2010 and 2 weeks in November 2011. A month before the beginning of the 2011 study, we provided an educational intervention on antibiotic prescribing for tonsillitis and otitis media for ED and paediatric junior trainees. This intervention had three components. First, we conducted interactive group tutorials with pre- and post-assessment of clinicians’ attitude to antibiotic prescribing. We also placed posters in the ED with a management flowchart based on the National Institute for Health and Care Excellence (NICE) guidelines for Respiratory Tract Infection (CG69 – http:// www.nice.org.uk). The third component of the intervention was the construction of an educational website (http:// www.antibioticsforkids.com) with information on the management of otitis media and tonsillitis. The participating doctors were not informed that the retrospective study would be carried out. Comparison was made with the results of the study in November 2010. This study was conducted as a service evaluation of current NICE guidance. Overall, 2141 children were seen, of whom 303 (14%) received antibiotics. The commonest diagnoses for which antibiotics were prescribed in both years are shown in Table 1. The three most frequently prescribed antibiotics were amoxicillin, amoxicillin/clavulanic acid and phenoxymethylpenicillin. Overall, fewer antibiotics were prescribed in the second year. After the educational intervention, reductions of antibiotic prescribing by 32% and 25% were observed for otitis media and tonsillitis, respectively (Table 1). This study shows that there is scope to change antibiotic prescribing patterns in the paediatric ED following an educational initiative, but larger studies are required to assess the true impact of such an educational tool. The use of a website for the purpose of antibiotic stewardship has been implemented in many institutions worldwide.2,3 Education needs to target the decision-making processes of physicians and engage interest to effectively reduce unnecessary antibiotic prescribing. There is also a need to determine the optimal methodology to maintain these outcomes within an antibiotic stewardship program in the paediatric ED.
Journal of Paediatrics and Child Health 50 (2014) 932–935 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
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Letters to the Editor
Table 1 Antibiotic prescribing in the paediatric emergency department in both years of the study for the commonest diagnoses and comparison between the two years 2010 Diagnosed Upper respiratory tract infection Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Lower respiratory tract infection Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Unknown Tonsillitis Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Unknown Otitis media Total, n (%)‡ Age group, n ≤3 >3–8 >8–16
2011 Prescribed antibiotics
P value†
Diagnosed
Prescribed antibiotics
7 (6)
157 (14)
14 (8.9)
6 0 1
110 41 6
NS 112 (18.6) 83 22 7
9 4 1 NS
34 (5.6)
28 (82)
35 (3)
26 (74)
28 5 1 0
22 5 1 0
19 11 3 2
14 11 1 0
32 (5.3)
26 (81)
30 (2.7)
15 (50)
18 11 3 0
14 9 3 0
16 12 1 1
28 (4.6)
23 (82)
18 (1.6)
17 9 2
14 7 2
11 6 1
0.007
7 7 0 1 NS 12 (55) 7 4 1
†P values were calculated using Fisher’s exact test due to the small numbers. ‡For number of patients diagnosed, the quantity in parentheses is patients diagnosed as a proportion of total patients seen; for number of patients prescribed antibiotics, it is patients prescribed antibiotics as a proportion of total patients diagnosed. NS, not significant.
Dr Despoina Gkentzi1 Dr Rohana Ramachandran1 Dr Elisabeth Day1 Dr Lazarus Anguvaa1 Dr Malcolm Borg2 Dr Naren Siva1 Dr Jonathan Sturgeon1 Dr Thiagarajan Jaiganesh2 Dr Mike Sharland1 Dr Katja Doerholt1 1 Paediatric Infectious Diseases Unit St. George’s Hospital London, United Kingdom2Emergency Department St. George’s Hospital London, United Kingdom
References 1 Sands R, Shanmugavadivel D, Stephenson T, Wood D. Medical problems presenting to paediatric emergency departments: 10 years on. Emerg. Med. J. 2012; 29: 379–82.
2 Pagani L, Gyssens IC, Huttner B, Nathwani D, Harbarth S. Navigating the web in search of resources on antimicrobial stewardship in health care institutions. Clin. Infect. Dis. 2009; 48: 626–32. 3 Dubos F, Nicolini G, Bielicky J, Sharland M. Qualitative review of web-based professional education on antibiotic prescribing for children: 10 million hits, but only 10 good web sites. J. Ped. Infect. Dis. 2013; doi: 10.1093/jpids/pit063.
Dear Editor, CASE OF INFANTILE ONYCHOMYCOSIS SUCCESSFULLY CURED BY 5% AMOROLFINE NAIL LACQUER A 16-month-old boy in good health presented asymptomatic alterations in the toenails on his left foot of approximately half year’s evolution. His mother had been diagnosed of
Funding sources: None. Conflict of interest: None declared.
Journal of Paediatrics and Child Health 50 (2014) 933–935 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
933
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
doi:10.1111/jpc.12751
Letters to the Editor Dear Editor, THE IMPORTANCE OF PHYSICAL EXAMINATION IN PATIENTS WITH MENTAL HEALTH PRESENTATIONS An 8-year-old girl was referred by her GP to the out-patient department for assessment of learning difficulties. She was triaged to the Behaviour Clinic. At the appointment, her mother expressed concern about the limited support her daughter was receiving at school and also requested a brain scan to investigate her poor memory. It was immediately apparent that the mother had poor cognitive function, with limited understanding about her daughter’s symptoms, capacities and needs. On physical examination the girl appeared generally healthy and non-dysmorphic. A large (approximately 8 × 10 cm), firm, non-tender mass was palpated in the lower central abdomen. On further questioning, neither the mother nor the girl were able to provide much information regarding the mass or how long it had been there. The mother thought it was due to constipation. An urgent ultrasound was arranged. The appearance was consistent with a complex ovarian teratoma. She was referred to the paediatric gynaecologists and underwent laparoscopic resection without complication. She recovered well from the operation and returned to the Behaviour Clinic for on-going care. Over recent decades, an increasing proportion of the casemix of paediatricians in Australia involves developmental, behavioural and mental health problems.1,2 Doctors provide skilled assessment and management of developmental and mental health problems in children, including referrals to other health, education and social service care providers. However, it is also incumbent upon doctors to take a full history and perform a physical examination to exclude any causative or unrelated medical condition. Many children have limited contact with medical professionals, and so it is important to perform a thorough medical evaluation when they are seen. In addition, preventive health care issues such as nutrition, exercise, minimising ‘screen time’ and immunisation should be discussed. This case illustrates the importance of taking the opportunity to ‘do the doctor thing’. This is particularly important when seeing families with low cognitive function or psychosocial disadvantage. Dr Doris Tham1 Dr Daryl Efron2,3,4 1 Paediatric Registrar, Centre for Community Child Health, 2 Paediatrician, The Royal Children’s Hospital, 3Senior Research Fellow, Murdoch Childrens Research Institute, and 4 Senior Lecturer, Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
References 1 Hewson PH, Anderson PK, Dinning AH et al. A 12 month profile of community paediatric consultations in Barwon region. J. Paediatr. Child Health 1999; 35: 16–23.
Conflict of interest: There is no conflict of interest connected to this paper.
932
2 Hiscock H, Roberts G, Efron D et al. Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network. Med. J. Aust. 2011; 194: 392–7.
Dear Editor, ANTIBIOTIC PRESCRIBING IN THE PAEDIATRIC EMERGENCY DEPARTMENT AND THE IMPACT OF EDUCATION Increasing numbers of children in the UK are attending the emergency department (ED).1 Data on antibiotic prescribing in this setting are limited. We aim to describe antibiotic prescription in a busy UK paediatric ED and to assess the impact of a targeted educational programme on optimal antibiotic prescribing. We conducted a retrospective study of all children attending the ED for 2 weeks in November 2010 and 2 weeks in November 2011. A month before the beginning of the 2011 study, we provided an educational intervention on antibiotic prescribing for tonsillitis and otitis media for ED and paediatric junior trainees. This intervention had three components. First, we conducted interactive group tutorials with pre- and post-assessment of clinicians’ attitude to antibiotic prescribing. We also placed posters in the ED with a management flowchart based on the National Institute for Health and Care Excellence (NICE) guidelines for Respiratory Tract Infection (CG69 – http:// www.nice.org.uk). The third component of the intervention was the construction of an educational website (http:// www.antibioticsforkids.com) with information on the management of otitis media and tonsillitis. The participating doctors were not informed that the retrospective study would be carried out. Comparison was made with the results of the study in November 2010. This study was conducted as a service evaluation of current NICE guidance. Overall, 2141 children were seen, of whom 303 (14%) received antibiotics. The commonest diagnoses for which antibiotics were prescribed in both years are shown in Table 1. The three most frequently prescribed antibiotics were amoxicillin, amoxicillin/clavulanic acid and phenoxymethylpenicillin. Overall, fewer antibiotics were prescribed in the second year. After the educational intervention, reductions of antibiotic prescribing by 32% and 25% were observed for otitis media and tonsillitis, respectively (Table 1). This study shows that there is scope to change antibiotic prescribing patterns in the paediatric ED following an educational initiative, but larger studies are required to assess the true impact of such an educational tool. The use of a website for the purpose of antibiotic stewardship has been implemented in many institutions worldwide.2,3 Education needs to target the decision-making processes of physicians and engage interest to effectively reduce unnecessary antibiotic prescribing. There is also a need to determine the optimal methodology to maintain these outcomes within an antibiotic stewardship program in the paediatric ED.
Journal of Paediatrics and Child Health 50 (2014) 932–935 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
bs_bs_banner
Letters to the Editor
Table 1 Antibiotic prescribing in the paediatric emergency department in both years of the study for the commonest diagnoses and comparison between the two years 2010 Diagnosed Upper respiratory tract infection Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Lower respiratory tract infection Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Unknown Tonsillitis Total, n (%)‡ Age group, n ≤3 >3–8 >8–16 Unknown Otitis media Total, n (%)‡ Age group, n ≤3 >3–8 >8–16
2011 Prescribed antibiotics
P value†
Diagnosed
Prescribed antibiotics
7 (6)
157 (14)
14 (8.9)
6 0 1
110 41 6
NS 112 (18.6) 83 22 7
9 4 1 NS
34 (5.6)
28 (82)
35 (3)
26 (74)
28 5 1 0
22 5 1 0
19 11 3 2
14 11 1 0
32 (5.3)
26 (81)
30 (2.7)
15 (50)
18 11 3 0
14 9 3 0
16 12 1 1
28 (4.6)
23 (82)
18 (1.6)
17 9 2
14 7 2
11 6 1
0.007
7 7 0 1 NS 12 (55) 7 4 1
†P values were calculated using Fisher’s exact test due to the small numbers. ‡For number of patients diagnosed, the quantity in parentheses is patients diagnosed as a proportion of total patients seen; for number of patients prescribed antibiotics, it is patients prescribed antibiotics as a proportion of total patients diagnosed. NS, not significant.
Dr Despoina Gkentzi1 Dr Rohana Ramachandran1 Dr Elisabeth Day1 Dr Lazarus Anguvaa1 Dr Malcolm Borg2 Dr Naren Siva1 Dr Jonathan Sturgeon1 Dr Thiagarajan Jaiganesh2 Dr Mike Sharland1 Dr Katja Doerholt1 1 Paediatric Infectious Diseases Unit St. George’s Hospital London, United Kingdom2Emergency Department St. George’s Hospital London, United Kingdom
References 1 Sands R, Shanmugavadivel D, Stephenson T, Wood D. Medical problems presenting to paediatric emergency departments: 10 years on. Emerg. Med. J. 2012; 29: 379–82.
2 Pagani L, Gyssens IC, Huttner B, Nathwani D, Harbarth S. Navigating the web in search of resources on antimicrobial stewardship in health care institutions. Clin. Infect. Dis. 2009; 48: 626–32. 3 Dubos F, Nicolini G, Bielicky J, Sharland M. Qualitative review of web-based professional education on antibiotic prescribing for children: 10 million hits, but only 10 good web sites. J. Ped. Infect. Dis. 2013; doi: 10.1093/jpids/pit063.
Dear Editor, CASE OF INFANTILE ONYCHOMYCOSIS SUCCESSFULLY CURED BY 5% AMOROLFINE NAIL LACQUER A 16-month-old boy in good health presented asymptomatic alterations in the toenails on his left foot of approximately half year’s evolution. His mother had been diagnosed of
Funding sources: None. Conflict of interest: None declared.
Journal of Paediatrics and Child Health 50 (2014) 933–935 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
933
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
